When to assume supply issues?

LnR70707 · August 2013

I had major supply issues with DS, most likely due to retained placenta (D&E post delivery, but a hysteroscopy a year later found retained tissue). Coupled with him being a preemie, I mostly EPed and supplemented....fenugreek and blessed thistle did nothing, at 6 weeks PP I was pumping every 3 hrs and getting 8oz a day. Reglan doubled that and domperidone eventually got me to 24oz a day around 5 months PP.

DD was term but also landed in the NICU, thankfully for only 3 days so I was able to nurse her every single feeding except one. I did have to pump the first night since they placed an NG tube and withheld feedings for roughly 12 hrs while she was under observation for choking/apnea episodes. While there she also had trouble maintaining her blood sugar level, so we opted to supplement after nursing to get her home asap (I pumped after every feed). We've slowly dropped the supplementation and she doesn't seem to be starving or wanting to eat more frequently without it. In my opinion, nursing is going 100 times better with DS, but at 6 days old she was down 8oz and at 10 days old she had gained none of that back. We try to keep her on a schedule of every 2.5 hrs, allowing one 4 hr stretch at night and I pump if she falls asleep after only side or nurses less than 10 minutes each side. Pumping 1 hr after a feeding only gets 10-20ml and if I give a bottle of BM and pump in place of a feeding I get about 1.5oz combined 2.5-3hrs after nursing. Her next weight check is Monday and a weighted feed after one side yesterday showed I transferred an ounce, but I don't want to wait as long as I did with DS to increase my supply if I'm headed in the low supply direction again. I still have Dom leftover from DS, but I don't want a ridiculous oversupply either.

RootBeer29 · August 2013

Is she having plenty of wet and dirty diapers?

LnR70707 · August 2013

RootBeer29 said:

Is she having plenty of wet and dirty diapers?

her diaper isn't consistently wet every feeding, but her daily totals are still within normal range.

Winomama · August 2013

I would nurse her more. Try not to look at the clock but follow her cues. She should be nursing closer to every 1.5-2 hours, If she is not back to her birth weight by Monday, her doctor will probably want to supplement with formula. Frequent feeding and emptying of the breasts is the best way to amp up your milk supply, which isn't fully established and regulated until 4-6 weeks. Strip her down to her diaper and do skin to skin contact before and during the feeds to get her to nurse longer.

LnR70707 · August 2013

AmyG* said:

Winomama said:

I would nurse her more. Try not to look at the clock but follow her cues. She should be nursing closer to every 1.5-2 hours, If she is not back to her birth weight by Monday, her doctor will probably want to supplement with formula. Frequent feeding and emptying of the breasts is the best way to amp up your milk supply, which isn't fully established and regulated until 4-6 weeks. Strip her down to her diaper and do skin to skin contact before and during the feeds to get her to nurse longer.

I would probably recommend the above. For at least 24 hours, do every 2 hours from start of one feeding to start of the next. Nag baby to nurse longer, tickle toes, sit baby up at the waist, switch sides, cool washcloth on the toes, use breast compressions and massage to speed the flow of milk.
I wouldn't worry about pumping or how much you can pump. Most moms this age can't pump much at all and that is normal. Remember when born baby's tummy is the size of a marble, the it stretches to the size of a shooter marbe, then a golf ball and should be about the size of their fist. A baby at >3weeks til about 6+ mos and taking in a lot of solids only takes in about 25 oz a day. So at 6 days, I'd expect 1 oz every feeding to be normal with it going up to about 1.5 oz soon[7-10 day growth spurt], then 2 oz, then getting into a 2.5-3 oz every 2.5-3 hour right after 3 week growth spurt.
Figure weight gain from lowest weight. You should begin to see 1/2-1 oz per day, or 4-7 oz per week soon, which is normal weight gain for a bfed baby. And yes, at that rate, baby may not regain to birthweight by 2 weeks of age and that's still ok. Increase feeddings in 24 hour period, lots of skin to skin contact which increases baby's instinct to nurse as well as raises your prolactin level (which is what Dom does).
I don't assume supply problem unless you see continued weight loss or super low weight gain (less than 1/2 oz per day or 4 oz per week), and then it is more likely to be a baby latch issue rather than supply. Are you experiencing nipple damage or very sore nips? Has baby been evaluated for a tongue tie including side, posterior and lip ties?

Thanks for the advice, she is already a very sleepy eater at times but she does cluster feed on her own so I will encourage more frequent feedings when I can. I do not have any damage....some soreness, particularly when we have nights like last night where she only goes about 20-40min between several feedings. We had a home nurse/LC evaluate her as part of our NICU discharge, and she said her latch was very good and when she is fully awake she does seem to have a good suck and remove milk efficiently.

SweetPeaK26 · August 2013

Sounds like she just needs more nursing sessions. Is she jaundice at all? This was my issue with dd2, and by 2 weeks old she was still 10oz under her birth weight an her jaundice was so bad she was put into the hospital. They fully believe that the two caused each other, because milk supply didn't seem to be the issue. Once she had more energy from getting rid of the jaundice, she put on weight right away.

My point is that a sleepy eater, for whatever reason, will keep baby a sleepy eater because they won't take in enough calories to boost their energy. The more you annoy her to keep her up and and eating, the more energy she will have to pu towards eating.

At our hospital, they have her 2 oz of formula after I nursed her that first night (at the 2 weeks jaundice hospitalization) and she sucked it down. I cried. The hospital pedi told me that it wasn't me (LC confirmed as I was still dripping milk after she was done nursing) but that its so much easier that they'll take it. After that, i'd nurse, pump the other side, and feed the pumped milk as soon as I was done nursing. A few days of that and she was alert and gaining. We quit the bottle and she just nursed then, no more issues.

LnR70707 · August 2013

SweetPeaK26 said:

Sounds like she just needs more nursing sessions. Is she jaundice at all? This was my issue with dd2, and by 2 weeks old she was still 10oz under her birth weight an her jaundice was so bad she was put into the hospital. They fully believe that the two caused each other, because milk supply didn't seem to be the issue. Once she had more energy from getting rid of the jaundice, she put on weight right away. My point is that a sleepy eater, for whatever reason, will keep baby a sleepy eater because they won't take in enough calories to boost their energy. The more you annoy her to keep her up and and eating, the more energy she will have to pu towards eating. At our hospital, they have her 2 oz of formula after I nursed her that first night (at the 2 weeks jaundice hospitalization) and she sucked it down. I cried. The hospital pedi told me that it wasn't me (LC confirmed as I was still dripping milk after she was done nursing) but that its so much easier that they'll take it. After that, i'd nurse, pump the other side, and feed the pumped milk as soon as I was done nursing. A few days of that and she was alert and gaining. We quit the bottle and she just nursed then, no more issues.

Her levels were fine when discharged and there is only a little yellowing of the eyes so I don't think jaundice is the culprit. Next weight check is tomorrow and we saw a different pedi in the practice last week, so I'll bring it up to our pedi again. I do follow with a bottle of BM or occasionally formula if I haven't managed to get anything with the pump after the prior feeding at night, sometimes she'll suck it down but usually if she is falling dead asleep at the breast she won't take more than 10-20ml from the bottle either. I haven't tried bottle feeding first because I thought that would make her more likely to give up at the breast.

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